RESEARCH ARTICLE
Sharing Responsibilities within the General Practice Team – A Cross-Sectional Study of Task Delegation in Germany Karola Mergenthal*, Martin Beyer, Ferdinand M. Gerlach, Corina Guethlin Institute of General Practice, Goethe-University Frankfurt, Frankfurt/Main, Germany * [email protected]
a11111
Abstract Background
OPEN ACCESS Citation: Mergenthal K, Beyer M, Gerlach FM, Guethlin C (2016) Sharing Responsibilities within the General Practice Team – A Cross-Sectional Study of Task Delegation in Germany. PLoS ONE 11(6): e0157248. doi:10.1371/journal.pone.0157248 Editor: Massimo Ciccozzi, National Institute of Health, ITALY
Expected growth in the demand for health services has generated interest in the more effective deployment of health care assistants. Programs encouraging German general practitioners (GPs) to share responsibility for care with specially qualified health care assistants in the family practice (VERAHs) have existed for several years. But no studies have been conducted on the tasks German GPs are willing to rely on specially qualified personnel to perform, what they are prepared to delegate to all non-physician practice staff and what they prefer to do themselves.
Received: April 9, 2016 Accepted: May 26, 2016 Published: June 9, 2016 Copyright: © 2016 Mergenthal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Methods As part of an evaluation study on the deployment of VERAHs in GP-centered health care, we used a questionnaire to ask about task delegation within the practice team. From a list of tasks that VERAHs are specifically trained to carry out, GPs were asked to indicate which they actually delegate. We also asked GPs why they had employed a VERAH in their practice and for their opinions on the benefits and limitations of assigning tasks to VERAHs. The aim of the study was to find out which tasks GPs delegate to their specially qualified personnel, which they permit all HCAs to carry out, and which tasks they do not delegate at all.
Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: The trial was funded by the AOK Baden Wuerttemberg and the Hausaerztliche Vertragsgemeinschaft Baden-Wuerttemberg. The analysis was carried out completely independently. The sponsor had no influence in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist.
Results The survey was filled in and returned by 245 GPs (83%). Some tasks were exclusively delegated to VERAHs (e.g. home visits), while others were delegated to all HCAs (e.g. vaccinations). About half the GPs rated the assessment of mental health, as part of the comprehensive assessment of a patient’s condition, as the sole responsibility of a GP. The possibility to delegate more complex tasks was the main reason given for employing a VERAH. Doctors said the delegation of home visits provided them with the greatest relief.
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
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Sharing Responsibilities within the General Practice Team
Conclusions In Germany, where GPs are solely accountable for the health care provided in their practices, experience with the transfer of responsibility to other non-physician health care personnel is still very limited. When HCAs have undergone special training, GPs seem to be prepared to delegate tasks that demand a substantial degree of know-how, such as home visits and case management. This “new” role allocation within the practice may signal a shift in the provision of health care by family practice teams in Germany.
Introduction In an aging population, it is increasingly difficult for primary care providers to deliver appropriate health care to a rising number of chronically ill patients. In some countries, it is standard practice to employ qualified nurses in primary care. In Germany, however, GPs generally employ health care assistants (HCAs) who work under the supervision of a GP. Health care assistants are increasingly being trained to take on additional responsibilities, but GPs remain legally accountable for the health care provided in their practices. HCAs that receive additional training are referred to as “health care assistants in the family practice (VERAHs)” [1]. In other countries they are called “medical assistants” [2], “physician assistants” [3], “healthcare assistants” [4], or in a broader sense “allied health assistants” [5]. The overarching aim is to increase the efficiency of comprehensive health care by delegating tasks, and thus sharing responsibility. Medical assistants are traditionally given rather minor tasks to do, such as measuring blood glucose, and applying wound dressings [2]. VERAHs, however, are trained to take on a new role: Following their initial qualification (lasting 3 years), they undergo an extra 200 hours of training during which they explicitly learn to perform more of the tasks needed in the care of chronically ill patients, such as carrying out routine home visits, team-based case management, supporting patients in the coordination and organization of their treatment, assessment of physical and mental health as part of a comprehensive assessment, certain tasks in preventive medicine, and wound care. The professional training of an HCA in Germany lasts three years, of which 1–2 days a week are spent at a vocational school an d3-4 days in a practice. HCAs perform clinical tasks such as taking blood samples, intramuscular injections, ECGs and spirometries. After working for 2 years, it is possible to obtain the VERAH qualification (it costs 1,850–2,600 € to qualify as a VERAH). GPs that have signed a contract with one of the major health insurance plans in Baden-Wuerttemberg are compensated for employing a VERAH. VERAHs are expected to perform the tasks named above, but the GP still decides which tasks to delegate and to whom. From a legal perspective, GPs in Germany remain accountable for all health care services provided in their practices, regardless of whether they share the responsibility (the word responsibility being used in a broad sense throughout this document) for performing certain tasks with other practice staff. In such a health care system, delegation means assigning specific tasks to qualified health care personnel but remaining responsible and legally accountable for the health care of a patient. In Germany, although VERAHs are required to explain and monitor medication as part of routine care management, many tasks, such as advising patients how and when to take their medicine, are still regarded as the responsibility of the physician. The introduction of new roles demands an understanding of alternative ways of organizing team-based care, and the outcomes that may result. Data for Germany is scarce, but available information shows that jointly
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
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Sharing Responsibilities within the General Practice Team
performed interventions (by GP and HCA) can improve the care of patients with osteoarthritis, depression and heart failure [6–8]. Team-based care can result in higher patient satisfaction [9], reduction of acute care utilization [10], greater compliance and a closer bond to the general practice team [11]. Furthermore, practice teams see the new responsibilities of HCAs as an effective resource that leads to a general improvement in health care, particularly of chronically ill patients [12– 13]. Studies from abroad have also shown that doctors hope that hiring physician assistants will give them more time for complex patients and reduce stress levels at work [14]. Uncertainty with regard to funding and which tasks to delegate, as well as the assistants’ need for supervision and training, has resulted in widespread skepticism [14]. A systematic review summarizing the new responsibilities and advantages and disadvantages of employing allied health assistants shows that the main benefit appears to be an improvement in service quality as a result of an increase in patient orientation, while disadvantages concern mainly role confusion due to unclear responsibilities [5]. Role confusion may also reflect physician inexperience in sharing responsibility for certain tasks with new healthcare personnel. In order to study the transfer of responsibilities within the practice team (consisting of the GP, a specially trained HCA, or VERAH, and other HCAs) we explicitly asked GPs to describe the tasks they routinely delegate. The aim of the study was to explore which tasks GPs delegate to their specially qualified personnel, which they permit all HCAs to carry out, and which tasks they do not delegate at all (i.e. tasks they carry out themselves, or are not carried out in the practice at all). We also looked at the factors encouraging GPs to employ a VERAH in their practices and asked about the benefits and limitations of assigning tasks to VERAHs.
Materials and Methods Ethics approval The study was approved in June 2011 by the ethical review committee of the University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany (Geschafts-Nr.:263/11).
Study population The study population consisted solely of general practitioners, who had participated in a special “structured health plan” (GP-centered care, Hausarztzentrierte Versorgung, HzV) in the federal state of Baden-Wuerttemberg. Baden-Wuerttemberg covers a surface area of 35 million square kilometers and has 10 million inhabitants. It has 10 towns with a population of over 100,000. The “structured health plan” aims to enhance health care for patients with chronic diseases and complex health care needs (e.g., those requiring long-term care). Participation in the “structural health plan” is voluntary, but it includes additional reimbursement for the care of chronically ill patients, provided that the practice employs a VERAH. The recruitment took place in two steps. Firstly, we invited all of the 909 practices that had participated in the structured health plan in 2011, and employed a VERAH, to take part in the survey. The invitation included study information, a declaration of consent, a questionnaire and a stamped addressed envelope to return the study documents. Secondly, we invited the VERAHs to give the GPs in the practice an information package containing a special questionnaire (see S1 File) for them to fill out. The study commenced between July and September 2011.
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
3 / 12
Sharing Responsibilities within the General Practice Team
Survey instrument The survey was conducted on the basis of a self-developed questionnaire that focused on the reasons for and the consequences of employing a VERAH, as well as on delegation in general. From a list of the tasks (e.g. Home visits, wound management, vaccination management) that the VERAHs are specifically trained to carry out, the GPs were asked to indicate which they actually delegate to a VERAH, which to all non-physician staff, and which they generally perform themselves, The GPs were additionally asked to provide information in free text on the main advantages and disadvantages of employing a VERAH. One item in the survey asked about the reasons for employing a VERAH (1. The possibility to improve the health care of chronically ill patients; 2. The possibility to save time; 3. The possibility to delegate home visits). Another item asked about general changes resulting from this type of team-based care. The items included in the questionnaire were decided upon following the analysis of data derived from focus groups we conducted with HCAs, and from 2 interviews carried out with GPs. It was pilot tested in 10 general practices.
Statistical analysis The software program IBM SPSS (Statistics Version 20.0) was used to analyze the data descriptively. Missing data could be deducted from giving N in all tables. N includes only complete data sets. Information provided in free text was evaluated using semi-qualitative content analysis, i.e. categories were created, and statements were coded and counted.
Results Characteristics of participating general practitioners VERAHs at 294 practices participated in the survey. Physicians from 245 of these practices also took part in the survey, corresponding to a response rate of 83.3%. The average age of participating physicians was 54 years (SD 8.5), more than three quarters of them were male (77%), and they had worked in general practice for an average of 18 years (SD 8.5). Almost three quarters of the participating practices were rural (73%) which differed from all GPs in the GP-centered health care program (see Table 1). Overall, an average of 1.82 GPs (SD 1.25) and 4.68 HCAs (SD 2.25) worked in each practice, and around half of the practices were solo-practices (56%) (see Table 1). The HCAs with the additional qualification (VERAHs) had worked in their practices for an average of 12.5 years (SD 8.6).
Delegation Tasks assigned to VERAHs and other practice staff. 63% of participating physicians said they relied on VERAHs to conduct structured assessments of a patient’s physical condition, 59% of the GPs said VERAHs were exclusively responsible for carrying out home visits. 58% of GPs said that only VERAHs prepared patients’ care plans, and 49% said VERAHs were solely responsible for conducting case management assessments. Geriatric assessments were delegated either to VERAHs (44%), or to all staff members (38%). Documenting medically significant facts is either delegated to VERAHs or carried out by the GPs themselves: 34% delegate this task to a VERAH and 34% do it themselves. Other tasks (e.g. measurement of diagnostic parameters, simple medical procedures or vaccinations) were delegated to all practice staff (see Table 2).
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
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Sharing Responsibilities within the General Practice Team
Table 1. Characteristics of participating general practitioners in the state of Baden-Wuerttemberg. Family physicians (n = 245) Male gender (n; %)
184 (77.3)
Age in years (Mean; SD)
54.0 (7.48)
Years in private practice (Mean; SD)
18 (8.5)
Previous participation in research project (yes) (n; %)
108 (48.4)
Family practices (n = 237) Solo practice (n,%)
138 (56.3)
Joint practice (n,%)
99 (43.7)
Location of practice City (>100,000 inhabitants) (n; %)
18 (7.7)
Town (20,000–100,000 inhabitants) (n; %)
45 (19,2)
Rural town (5,000–20,000 inhabitants) (n; %)
106 (45.3)
Village (
Sharing Responsibilities within the General Practice Team – A Cross-Sectional Study of Task Delegation in Germany Karola Mergenthal*, Martin Beyer, Ferdinand M. Gerlach, Corina Guethlin Institute of General Practice, Goethe-University Frankfurt, Frankfurt/Main, Germany * [email protected]
a11111
Abstract Background
OPEN ACCESS Citation: Mergenthal K, Beyer M, Gerlach FM, Guethlin C (2016) Sharing Responsibilities within the General Practice Team – A Cross-Sectional Study of Task Delegation in Germany. PLoS ONE 11(6): e0157248. doi:10.1371/journal.pone.0157248 Editor: Massimo Ciccozzi, National Institute of Health, ITALY
Expected growth in the demand for health services has generated interest in the more effective deployment of health care assistants. Programs encouraging German general practitioners (GPs) to share responsibility for care with specially qualified health care assistants in the family practice (VERAHs) have existed for several years. But no studies have been conducted on the tasks German GPs are willing to rely on specially qualified personnel to perform, what they are prepared to delegate to all non-physician practice staff and what they prefer to do themselves.
Received: April 9, 2016 Accepted: May 26, 2016 Published: June 9, 2016 Copyright: © 2016 Mergenthal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Methods As part of an evaluation study on the deployment of VERAHs in GP-centered health care, we used a questionnaire to ask about task delegation within the practice team. From a list of tasks that VERAHs are specifically trained to carry out, GPs were asked to indicate which they actually delegate. We also asked GPs why they had employed a VERAH in their practice and for their opinions on the benefits and limitations of assigning tasks to VERAHs. The aim of the study was to find out which tasks GPs delegate to their specially qualified personnel, which they permit all HCAs to carry out, and which tasks they do not delegate at all.
Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: The trial was funded by the AOK Baden Wuerttemberg and the Hausaerztliche Vertragsgemeinschaft Baden-Wuerttemberg. The analysis was carried out completely independently. The sponsor had no influence in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist.
Results The survey was filled in and returned by 245 GPs (83%). Some tasks were exclusively delegated to VERAHs (e.g. home visits), while others were delegated to all HCAs (e.g. vaccinations). About half the GPs rated the assessment of mental health, as part of the comprehensive assessment of a patient’s condition, as the sole responsibility of a GP. The possibility to delegate more complex tasks was the main reason given for employing a VERAH. Doctors said the delegation of home visits provided them with the greatest relief.
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
1 / 12
Sharing Responsibilities within the General Practice Team
Conclusions In Germany, where GPs are solely accountable for the health care provided in their practices, experience with the transfer of responsibility to other non-physician health care personnel is still very limited. When HCAs have undergone special training, GPs seem to be prepared to delegate tasks that demand a substantial degree of know-how, such as home visits and case management. This “new” role allocation within the practice may signal a shift in the provision of health care by family practice teams in Germany.
Introduction In an aging population, it is increasingly difficult for primary care providers to deliver appropriate health care to a rising number of chronically ill patients. In some countries, it is standard practice to employ qualified nurses in primary care. In Germany, however, GPs generally employ health care assistants (HCAs) who work under the supervision of a GP. Health care assistants are increasingly being trained to take on additional responsibilities, but GPs remain legally accountable for the health care provided in their practices. HCAs that receive additional training are referred to as “health care assistants in the family practice (VERAHs)” [1]. In other countries they are called “medical assistants” [2], “physician assistants” [3], “healthcare assistants” [4], or in a broader sense “allied health assistants” [5]. The overarching aim is to increase the efficiency of comprehensive health care by delegating tasks, and thus sharing responsibility. Medical assistants are traditionally given rather minor tasks to do, such as measuring blood glucose, and applying wound dressings [2]. VERAHs, however, are trained to take on a new role: Following their initial qualification (lasting 3 years), they undergo an extra 200 hours of training during which they explicitly learn to perform more of the tasks needed in the care of chronically ill patients, such as carrying out routine home visits, team-based case management, supporting patients in the coordination and organization of their treatment, assessment of physical and mental health as part of a comprehensive assessment, certain tasks in preventive medicine, and wound care. The professional training of an HCA in Germany lasts three years, of which 1–2 days a week are spent at a vocational school an d3-4 days in a practice. HCAs perform clinical tasks such as taking blood samples, intramuscular injections, ECGs and spirometries. After working for 2 years, it is possible to obtain the VERAH qualification (it costs 1,850–2,600 € to qualify as a VERAH). GPs that have signed a contract with one of the major health insurance plans in Baden-Wuerttemberg are compensated for employing a VERAH. VERAHs are expected to perform the tasks named above, but the GP still decides which tasks to delegate and to whom. From a legal perspective, GPs in Germany remain accountable for all health care services provided in their practices, regardless of whether they share the responsibility (the word responsibility being used in a broad sense throughout this document) for performing certain tasks with other practice staff. In such a health care system, delegation means assigning specific tasks to qualified health care personnel but remaining responsible and legally accountable for the health care of a patient. In Germany, although VERAHs are required to explain and monitor medication as part of routine care management, many tasks, such as advising patients how and when to take their medicine, are still regarded as the responsibility of the physician. The introduction of new roles demands an understanding of alternative ways of organizing team-based care, and the outcomes that may result. Data for Germany is scarce, but available information shows that jointly
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
2 / 12
Sharing Responsibilities within the General Practice Team
performed interventions (by GP and HCA) can improve the care of patients with osteoarthritis, depression and heart failure [6–8]. Team-based care can result in higher patient satisfaction [9], reduction of acute care utilization [10], greater compliance and a closer bond to the general practice team [11]. Furthermore, practice teams see the new responsibilities of HCAs as an effective resource that leads to a general improvement in health care, particularly of chronically ill patients [12– 13]. Studies from abroad have also shown that doctors hope that hiring physician assistants will give them more time for complex patients and reduce stress levels at work [14]. Uncertainty with regard to funding and which tasks to delegate, as well as the assistants’ need for supervision and training, has resulted in widespread skepticism [14]. A systematic review summarizing the new responsibilities and advantages and disadvantages of employing allied health assistants shows that the main benefit appears to be an improvement in service quality as a result of an increase in patient orientation, while disadvantages concern mainly role confusion due to unclear responsibilities [5]. Role confusion may also reflect physician inexperience in sharing responsibility for certain tasks with new healthcare personnel. In order to study the transfer of responsibilities within the practice team (consisting of the GP, a specially trained HCA, or VERAH, and other HCAs) we explicitly asked GPs to describe the tasks they routinely delegate. The aim of the study was to explore which tasks GPs delegate to their specially qualified personnel, which they permit all HCAs to carry out, and which tasks they do not delegate at all (i.e. tasks they carry out themselves, or are not carried out in the practice at all). We also looked at the factors encouraging GPs to employ a VERAH in their practices and asked about the benefits and limitations of assigning tasks to VERAHs.
Materials and Methods Ethics approval The study was approved in June 2011 by the ethical review committee of the University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany (Geschafts-Nr.:263/11).
Study population The study population consisted solely of general practitioners, who had participated in a special “structured health plan” (GP-centered care, Hausarztzentrierte Versorgung, HzV) in the federal state of Baden-Wuerttemberg. Baden-Wuerttemberg covers a surface area of 35 million square kilometers and has 10 million inhabitants. It has 10 towns with a population of over 100,000. The “structured health plan” aims to enhance health care for patients with chronic diseases and complex health care needs (e.g., those requiring long-term care). Participation in the “structural health plan” is voluntary, but it includes additional reimbursement for the care of chronically ill patients, provided that the practice employs a VERAH. The recruitment took place in two steps. Firstly, we invited all of the 909 practices that had participated in the structured health plan in 2011, and employed a VERAH, to take part in the survey. The invitation included study information, a declaration of consent, a questionnaire and a stamped addressed envelope to return the study documents. Secondly, we invited the VERAHs to give the GPs in the practice an information package containing a special questionnaire (see S1 File) for them to fill out. The study commenced between July and September 2011.
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
3 / 12
Sharing Responsibilities within the General Practice Team
Survey instrument The survey was conducted on the basis of a self-developed questionnaire that focused on the reasons for and the consequences of employing a VERAH, as well as on delegation in general. From a list of the tasks (e.g. Home visits, wound management, vaccination management) that the VERAHs are specifically trained to carry out, the GPs were asked to indicate which they actually delegate to a VERAH, which to all non-physician staff, and which they generally perform themselves, The GPs were additionally asked to provide information in free text on the main advantages and disadvantages of employing a VERAH. One item in the survey asked about the reasons for employing a VERAH (1. The possibility to improve the health care of chronically ill patients; 2. The possibility to save time; 3. The possibility to delegate home visits). Another item asked about general changes resulting from this type of team-based care. The items included in the questionnaire were decided upon following the analysis of data derived from focus groups we conducted with HCAs, and from 2 interviews carried out with GPs. It was pilot tested in 10 general practices.
Statistical analysis The software program IBM SPSS (Statistics Version 20.0) was used to analyze the data descriptively. Missing data could be deducted from giving N in all tables. N includes only complete data sets. Information provided in free text was evaluated using semi-qualitative content analysis, i.e. categories were created, and statements were coded and counted.
Results Characteristics of participating general practitioners VERAHs at 294 practices participated in the survey. Physicians from 245 of these practices also took part in the survey, corresponding to a response rate of 83.3%. The average age of participating physicians was 54 years (SD 8.5), more than three quarters of them were male (77%), and they had worked in general practice for an average of 18 years (SD 8.5). Almost three quarters of the participating practices were rural (73%) which differed from all GPs in the GP-centered health care program (see Table 1). Overall, an average of 1.82 GPs (SD 1.25) and 4.68 HCAs (SD 2.25) worked in each practice, and around half of the practices were solo-practices (56%) (see Table 1). The HCAs with the additional qualification (VERAHs) had worked in their practices for an average of 12.5 years (SD 8.6).
Delegation Tasks assigned to VERAHs and other practice staff. 63% of participating physicians said they relied on VERAHs to conduct structured assessments of a patient’s physical condition, 59% of the GPs said VERAHs were exclusively responsible for carrying out home visits. 58% of GPs said that only VERAHs prepared patients’ care plans, and 49% said VERAHs were solely responsible for conducting case management assessments. Geriatric assessments were delegated either to VERAHs (44%), or to all staff members (38%). Documenting medically significant facts is either delegated to VERAHs or carried out by the GPs themselves: 34% delegate this task to a VERAH and 34% do it themselves. Other tasks (e.g. measurement of diagnostic parameters, simple medical procedures or vaccinations) were delegated to all practice staff (see Table 2).
PLOS ONE | DOI:10.1371/journal.pone.0157248 June 9, 2016
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Sharing Responsibilities within the General Practice Team
Table 1. Characteristics of participating general practitioners in the state of Baden-Wuerttemberg. Family physicians (n = 245) Male gender (n; %)
184 (77.3)
Age in years (Mean; SD)
54.0 (7.48)
Years in private practice (Mean; SD)
18 (8.5)
Previous participation in research project (yes) (n; %)
108 (48.4)
Family practices (n = 237) Solo practice (n,%)
138 (56.3)
Joint practice (n,%)
99 (43.7)
Location of practice City (>100,000 inhabitants) (n; %)
18 (7.7)
Town (20,000–100,000 inhabitants) (n; %)
45 (19,2)
Rural town (5,000–20,000 inhabitants) (n; %)
106 (45.3)
Village (
